Health insurance and contraceptive use, Indonesian Family Planning Census 2021

Abstract Objective To assess the association between health insurance coverage and sociodemographic characteristics, and the use of modern contraception in Indonesia. Method We used data from the 2021 Indonesian family planning census which included 38 408 597 couples. Contraception is covered by the national health insurance scheme: members are non-contributory (for poor families who do not make any monetary contribution) or contributory (for better-off families who pay for the insurance). We used regression analyses to examine the correlation between each type of health insurance (non-contributory, contributory, private or none) and contraceptive use and type of contraceptive used. Findings The prevalence of the use of modern contraceptives in Indonesia was 57.0% (21 897 319/38 408 597). Compared with not having health insurance, having health insurance was associated with a greater likelihood of contraceptive use, odds ratio (OR): 1.14 (95% confidence intervals, CI: 1.13–1.14) and OR: 1.01 (95% CI: 1.01–1.01) for women with non-contributory and contributory health insurance, respectively. Having private health insurance was associated with lower use of modern contraceptives (OR: 0.94; 95% CI: 0.94–0.94). Intrauterine devices, lactational amenorrhoea and tubal ligation were the most common forms of contraceptive used by women. Conclusion The prevalence of modern contraceptive use in Indonesia is lower than the 75% target of the 2030 sustainable development goals. As national health insurance positively correlated with modern contraceptive use, extending its coverage on remote Indonesian islands is recommended to increase the use of such contraceptive methods in those areas.


Introduction
Family planning, including modern contraceptive methods, is a globally recognized strategy for reducing maternal and neonatal mortality, particularly in low-and middle-income countries. 1 As a low-and middle-income country with 273 million inhabitants, Indonesia is seeking to end population growth for long-term economic and social well-being. 2 Indonesia's National Population and Family Planning Board was established in 1970, and it contributed to an increased prevalence of contraceptive use of about 60.0% between 1960 and 2002. 3 At the same time, the country halved its fertility rate from 5.6 to 2.6 births per woman. This decline, however, has stalled. Compared with other highly populous developing countries and countries in the World Health Organization (WHO) Region for South-East Asia, Indonesia's fertility rate has not changed greatly since 2002, and was 2.18 births per woman in 2020. 4,5 However, substantial variation exists between the Indonesian islands. For example, the fertility rate in Java and Bali is 1.98 births per woman, whereas the rates are 2.61 and 2.71 births per woman in Nusa Tenggara and Papua, respectively (Box 1). 3,6 The country's contraceptive prevalence increased by only 1.5% between 2007 and 2017, and its maternal mortality rate remains high at 305 deaths per 100 000 live births over the same period. 7 The stagnation of the fertility rate in Indonesia is largely because of a complicated devolution process that shifted control of family planning programmes from the national level to local governments in 2001. This change resulted in an unclear understanding of the roles and responsibilities of family planning governance. 8 An important issue of family planning services under the devolution system was that contraception services were no longer free of charge as they had been under the centralized system. Most local governments refused to pay for contraception services for their citizens. To solve this problem, the national government included contraception services within the national health insurance system in 2016. 9 The national health insurance system, a single-payer universal health coverage system, was implemented in Indonesia as a comprehensive national insurance scheme in 2014. 10 People covered by the scheme are enrolled in either the non-contributory (for poorer people) or contributory schemes (for salaried, non-salaried (paid by the hour or day) and self-employed workers and their family members). The government covers payments for the non-contributory scheme through national and local government budgets. For the contributory scheme, there are three classes of coverage with different fees and the cost is met by the participant of the scheme. With contraception services included in the national health insurance system, people from poor families can obtain free family planning counselling and modern contraception. The family planning services can be accessed at public and private clinics that have signed contracts with the Social Health Insurance Administration Body. This body is authorized by the government to provide health insurance programmes for the Indonesian people. With support of this body, national family planning agencies can employ family planning field workers to provide family planning education and consultation services across the country. Without health insurance, individuals would pay about 500 000 Indonesian rupiahs (equivalent to 35.7 United States dollars (US$)) for a contraceptive implant; 6-7 million Indonesian rupiahs (US$ 428.6) for tubal ligation and vasectomy; 40 000 Indonesian rupiahs (US$ 2.8) per injectable contraceptive; and 400 000 Indonesian rupiahs (US$ 28.6) for an intrauterine device. All these modern contraceptives are included in the insurance scheme and have been available free of charge to all members since 2016. 9 Few studies have evaluated the integration of family planning services into the national health insurance scheme in Indonesia. Most studies available were conducted before the integration, and focused on certain types of health insurance and certain regions. 11,12 Hence, the findings cannot be widely generalized. To understand the benefits of this policy in increasing the use of modern contraceptives and reducing fertility rates in Indonesia, it is important to determine the relationship between health insurance coverage and use of modern contraceptives. Thus, the main aim of our study was to identify whether the integration of family planning services into the national health insurance scheme was associated with the use of modern contraception in Indonesia.

Data source
We used data from the Indonesian Family Census 2021, 3,6 which is man-aged by the National Population and Family Planning Board. The census collected data from 220 038 950 individuals  (81.4% of the Indonesian population of  270 203 917 in 2020), 38 408 597 couples  aged 15-49 years old, and 66 206 546 households from 514 districts in Indonesia. See Table 1 for the age category according to marital status in the census data. The census asked questions on: (i) sociodemographic characteristics (age, sex, marital status, religion, education, employment status and health insurance coverage); (ii) family planning (including number of children, pregnancy status, contraception use, reasons for not using contraception, type of contraception used and access to family planning services); and (iii) family development (for example, participation in Posyandu (community-based health services) for children younger than 5 years, family access to the internet and marriage registration number).

Variables
The dependent variable for the analyses was the use (yes or no) of a modern method of contraception, that is, intrauterine device, implant, injection, lactational amenorrhoea, tubal ligation, pills, condoms and vasectomy. Respondents were asked, "Are you currently doing something or using any method to delay or avoid getting pregnant?" If respondents answered yes, the interviewer then asked, "What method are you using?" The independent variable was the type of health insurance coverage at the time of the census, that is, noncontributory public health insurance, contributory public health insurance or private health insurance. In the census, respondents were asked, "Do you currently have health insurance?" If the respondent answered yes, the interviewer then asked, "What type of health insurance do you currently have?" Sociodemographic, reproductive and obstetric characteristics, and previous experience with service use, are associated with contraception use. We based our conceptual framework on a previous model 13 illustrating the predisposing and enabling factors for the use of contraceptives (Fig. 1)

Statistical analysis
We used descriptive statistics for the demographic findings, type of contraceptive used and type of health insurance. We used logistic regression analysis to assess the correlation between each health insurance type and contraception use. The covariates included in the logistic regression analysis were: age; employment type; education; religion; having access to family planning field workers; wealth quartile; and island of residence. We report the odds ratios (OR) and 95% confidence intervals (CI) for the logistic regression analyses. We used Stata, version 17 (StataCorp. LP, College Station, United States of America) for all analyses. of females using modern contraceptives reported having no health insurance (online repository). 4 Only a minority of females aged 15-25 years were covered by any health insurance, whether public or private (online repository). 4 Of females who were not, or not yet employed (mostly housewives), 43.2% (9 151 885/21 185 747) were covered by non-contributory health insurance for poor families. A small proportion of non-employed females were covered by private insurance (2.8%; 588 417/21 185 747). About half of the females who had no formal education, and those who had completed elementary school were covered by the non-contributory health insurance for poor families: 46.9% (231 020/493 076) and 51.7% (

Families covered by non-contributory health insurance, (%)
Families covered by contributory health insurance, (%)

Families covered by private health insurance, (%)
Health insurance and contraceptive use, Indonesia Asri Maharani et al.

Use of contraception
The overall prevalence of the use of modern contraceptives in Indonesia was 57.0% (21 897 319/38 408 597). Fig. 4 shows the factors associated with the use of modern contraceptive methods for the total census population (38 408 597 eligible women). Controlling for confounding factors, women who were covered by non-contributory health insurance for poor families were 1.14 times (95% CI: 1.13-1.14) more likely to use modern contraceptives than women who did not have health insurance. Women covered by contributory health insurance for nonpoor families were 1.01 times (95% CI: 1.01-1.01) more likely to use modern contraceptives than women who did not have health insurance. In contrast, women covered by private health insurance were less likely to use modern contraceptives than women who did not have health insurance (OR: 0.94; 95% CI: 0.94-0.94). Other factors associated with greater use of contraceptives were age (older than 26 years); any employment versus retirement; education up to high school versus no schooling; and second wealth quartile and above versus first quartile.

Type of contraception used
Fig. 5 shows multivariable logistic regression analyses of the association between the use of each type of contraceptive and insurance coverage. All results were adjusted for confounding variables (results according to island of residence is available in the online repository). 4 Compared with uninsured women, women who were covered by noncontributory health insurance for poor families were more likely to use intrauterine devices, implants, lactational amenorrhoea and tubal ligation, and less likely to use pills or injections. Among women who had contributory health insurance for non-poor families, the likelihood of using tubal ligation was greater than for other contraceptive methods (OR: 1.72; 95% CI: 1.71-1.73). Compared with uninsured women, women who were covered by contributory health insurance were also more likely to use intrauterine devices and lactational amenorrhoea but less likely to use implants, injections or pills. Women with private health insurance were also more likely to use intrauterine devices, lactational amenorrhoea and tubal ligation. In addition, these women were less likely to use implants, injections and pills.
Men with any type of health insurance were more likely to use condoms and vasectomy than men who did not have health insurance. The likelihood of using condoms was highest among men with contributory health insurance for non-poor families (OR: 1.65; 95% CI: 1.63-1.66), while the highest likelihood of using vasectomy was among men who had non-contributory health insurance for poor families (OR: 1.57; 95% CI: 1.54-1.61).
Receiving information about family planning practices from family planning field workers was significantly associated with contraception use in all islands (online repository). 4

Discussion
In 2016, the Indonesian government began including family planning services in the national health insurance scheme. The integration of family planning services aimed to reduce financial barriers to modern contraception services under the decentralized family planning system. The main aim of our study was to examine whether the objective of the policy was achieved. We found that both contributory and non-contributory health insurance within the national health insurance scheme was associated with the use of modern contraceptive methods in 2021.
Our findings concur with earlier studies which reported the benefits of health insurance on family planning uptake. [14][15][16] Research has shown that having health insurance reduced financial barriers to and hence increased access to family planning in Rwanda and Türkiye. In Türkiye, integrated modern contraception services within national health insurance substantially reduced out-ofpocket costs, which in turn increased the use of modern contraceptives by women. 17 A study in Rwanda confirmed the benefit of integrated family planning services in health insurance in sustaining the use of modern contraceptives. 18 The relationships between health insurance coverage and use of modern contraceptives differed by the type of health insurance in our study. Having non-contributory health insurance for poor families was associated with greater use of contraceptives than being uninsured. In addition, the likelihood of using modern contraceptives was higher among individuals with non-contributory health insurance than among those with contributory health insurance. The results suggest that the health coverage provided by the government improves access to modern contraceptives, especially among low-income families. A study in the United States of America reported that, among low-income women, health insurance coverage was associated with higher odds of uptake of the most effective contraceptive methods or moderately effective methods. 19 Health insurance coverage may facilitate a shift to modern contraceptives among women. We also found health insurance coverage was associated with a higher uptake of more costly methods -that is, intrauterine devices, tubal ligation and vasectomy -and lower uptake of cheaper methods such as injections and pills. By contrast, having private health insurance was associated with a lower uptake of modern contraceptive methods. This finding might be because of differences in the services that the insurance companies cover. Some private insurance companies cover the costs of contraception while others do not, potentially limiting access to services.
The prevalence of the use of modern contraceptives in Indonesia was 57.0% (21 897 319/38 408 597). This prevalence is lower than the global proportion of women whose family planning needs are satisfied by modern methods (77.0%; 0.847 billion/1.1 billion). 20 Our findings show a prevalence of contraception use similar to the survey in the Philippines (57.2%; 2573/4497) and slightly higher than that in Myanmar (55.7%; 3925/7047). 21 However, the national figure masks substantial variations in prevalence among provinces and districts in Indonesia, as also indicated in our study. Of the women who were using a modern contraceptive method, 59.9% (13 119 320/21 897 319) were using injectable contraceptive methods. As suggested in previous studies, women choose this method because of its convenience (it is not taken daily), comfortable administration and comparatively widespread availability. This result is in line with findings from Ethiopia. 22 Child spacing is one of the main reasons why women use modern contraceptives, and injection is considered a convenient family planning method to achieve this goal.
Our finding that receiving information about family planning from family planning field workers had a significant influence on the use of contraceptives

Type of health insurance (Ref: no health insurance)
Covered by non-contributory health insurance for poor families 1.14 (1.13-1.14) Covered by contributory health insurance for non-poor families 1 Health insurance and contraceptive use, Indonesia Asri Maharani et al.
in all islands corroborates a previous study in Indonesia. 23 This earlier study showed that, among young married women, discussing family planning with health workers was associated with greater use of modern contraceptive methods. A study in Nigeria also found that discussing contraceptive methods with a health worker was associated with 1.21 higher odds of using modern contraceptive methods. 24 Health work-ers are influential in encouraging the use of contraceptives, as the family planning messages they deliver can highlight women's well-being and the benefits of delaying and spacing pregnancies. 25 Improving the quality of the communication between health workers and health-care users is important given its association with higher uptake levels and continued use of modern contraceptive methods. 26 The Indonesian government could improve the quality of communication by increasing the salaries of family planning workers, which would enable the recruitment of better qualified personnel to encourage participation in family planning. Our study has some limitations. First, the cross-sectional nature of the data limits our ability to draw causal inferences. Therefore, we can report only associations. Second, all assessments were based on respondents' self-reports, which may have resulted in substantial underestimates or overestimates of contraceptives they used, which could undermine the accuracy of our estimates of the prevalence of the uptake of modern contraceptives in Indonesia. Finally, only married women (couples) were asked about the use of modern contraceptives in the 2021 Indonesian family planning census. Future studies should include unmarried or divorced women to enable the findings to be generalized to all women in Indonesia.
In conclusion, incorporating family planning services in a universal health insurance package could be an important strategy to overcome the stagnant fertility rate in Indonesia under the decentralized health system. A considerable proportion of the women in the census did not have health insurance. Thus, the government should create initiatives to encourage women and families to join the health insurance scheme. For example, the government could provide a health insurance premium that is affordable for the general public; alternatively, premiums could be calculated based on income brackets. We identified the preferred type of modern contraceptive for each type of health insurance across the islands. This information can be used by policy-makers to better tailor their programmes based on the different needs of the populations in each island. ■ Acknowledgments AM, SJ and ME contributed equally to this work. We thank the Indonesia National Research and Innovation Agency (Badan Riset dan Inovasi Nasional).
Competing interests: None declared.